By Matthew P. Bars, MS, and Victor L. Marchione, MD, FCCP

Charlene Peters* is a 56-year-old African American woman with a smoking history of 31 pack years. She decided to quit after experiencing increased dyspnea "over the last few years."

Upon intake to our smoking cessation program, chest radiography findings revealed increased markings bilaterally. Pulmonary function studies showed moderate airflow obstruction and chest restriction and reduced D_LCO consistent with moderate COPD. Her advanced quantitative sputum cytology found moderate dysplasia, precipitating a CT scan of the chest. Unfortunately, the CT scan revealed a solid 2 cm by 4 cm lower lobe mass behind the heart.

The bad news continues. A PET scan was positive for carcinoma. As we write this, the patient is scheduled for surgery. Perhaps she'll receive chemotherapy after that. The patient successfully stopped smoking with our program months ago. We hope it isn't too late.

Although the diagnostic details may vary, this scenario is repeated almost 180,000 times per year. Like 70 percent of all smokers, Peters visited at least one physician at least once a year. Although occasionally advised to stop, it wasn't until her visit to the smoking program at the Institute for Better Breathing, Jersey City, N.J., that she received a prescription and specific help for her tobacco addiction.

This situation is tragic for smokers like Peters and frustrating for many in the health care field. It seems clear that unless the medical community is more aggressive in treating the nation's largest public health problem, reducing smoking-related deaths and disease will be an uphill battle.

BARRIERS

Most smokers receive little if any help quitting smoking. This is even more amazing when considering that 25 percent of the nation's adult population smokes and that smoking-related diseases claim almost 1,200 lives daily.

Why is it that so few health care providers address such a ubiquitous and devastating disease? Four interrelated reasons provide the answer: training, time, success and reimbursement.¹ Many physicians believe: Why should I expend valuable office time for an intractable problem with poor outcomes for which I am not trained and for which I will not be paid?

We have enjoyed some success in helping health care professionals overcome these barriers and in helping even hardcore recalcitrant smokers quit. Our efforts are based on the national standard of care recommended by Michael Fiore, MD, and his colleagues at the Agency for Healthcare Research and Quality, and aggressively titrating the medications available to treat tobacco addiction.

FIVE As & FOUR Rs

Dr. Fiore and his colleagues reviewed thousands of smoking cessation studies to determine what works. They concluded that, at the very least, every patient should be asked if they smoke, advised to quit if they do, assessed and assisted in the quitting process and follow-up visits arranged.

Every health care professional should discuss the risks of tobacco use with every smoker, and those risks should be relevant to the smoker's specific life and health circumstances. The rewards of cessation also need to be emphasized, and these should be repeated at every office visit.

This isn't as hard as it may seem initially. Indeed, many practitioners may be performing these As and Rs as a matter of clinical routine. Imagine a pulmonologist reading a smoker's chest film. The doctor turns to the patient and says: "I see the effects of your smoking here. There are increased markings caused by 20 years of smoking a pack and one-half per day. Your lungs are hyperinflated consistent with inflammation and obstruction of the small airways. This is the first place we see damage from smoking. It isn't too late. There are new medications we can use to help you stop. What do you say we give it a try?"

In the above scenario the lung specialist has asked about smoking status, advised the patient to quit, assessed the smokers' readiness to quit and is prepared to assist the patient in that effort with medications and follow-up appointments. The doctor also is discussing the risks of smoking with this patient and is making those risks relevant to the smoker's particular situation.

This type of "medical biofeedback" can be used with spirometry, D_LCOs and lung volumes, cholesterol and blood sugar screenings, EKGs, simple chest auscultation and blood pressure measurements. Smoking affects virtually every cell and organ. Consequently, the opportunities for intervention are limited only by the clinician's imagination.

MEDICATIONS ARE ESSENTIAL

The reasons why more than 50 percent of our patients enjoy a one-year success rate aren't a secret. Any physician with a desire and commitment to help their patients and their community can prevail in treating tobacco addiction. We routinely teach physicians how.

Above and beyond the As and the Rs, we now know that medications are an essential part of any successful program. Medications to treat tobacco addiction are divided into two general categories: non-nicotine medications and nicotine replacement therapies (NRTs).

Currently, the only non-nicotine medication FDA approved for smoking cessation is buproprion SR (150 mg). One clear advantage that buproprion SR provides is the ability to begin medication prior to an actual target quit date.

Very few smoking patients are prepared to throw away their cigarettes the day of their medical office visit, especially if this is the first time the clinician has discussed quitting with them. Buproprion SR allows an opportunity for the clinician and the smoker to "wean into the quitting process." We have observed that within 14 days of using buproprion SR many patients can successfully quit and many others have significantly cut down.

These patients often report cigarettes "tasting bad"–what we have termed "tobacco taste perversion." Some report that their first daily cigarette is delayed several hours instead of immediately upon awakening A good rule of thumb: The sooner the first daily cigarette after awakening the more severe the tobacco addiction. Other idiosyncratic responses of buproprion SR we have observed prior to quitting include fewer puffs per cigarette and patients "forgetting to smoke."

COMBINATION THERAPIES

Some patients are able to quit with buproprion SR alone, however, many of our patients utilize combination therapies, including buproprion SR and one or more forms of nicotine replacement therapies. Nicotine replacement therapies consist of nicotine gum (2 mg and 4 mg; mint, orange or regular flavor), nicotine nasal spray, nicotine inhaler and nicotine transdermal patches. The nicotine patches are available in 22 mg, 21 mg, 15 mg, 14 mg and 7 mg strengths. They're designed to be applied upon awakening and to be removed at bedtime or the following morning. All these medications are fairly benign and usually well tolerated.

Nortriptyline and clonidine have been recommended as second line medications. See the product inserts for contraindications, warnings, precautions and adverse drug reactions.

Those of us who routinely treat smokers now realize that one of the biggest problems in successfully treating tobacco addiction is underdosing. It's not uncommon for us to interview a three-pack-a-day smoker who was told by a physician not to use a nicotine patch because he might get too much nicotine!

David P. L. Sachs, MD, FCCP, of the Palo Alto Center for Pulmonary Disease Prevention, Palo Alto, Calif., and others have shown that it's helpful (perhaps essential) to use as much medication as the patient needs for as long as they need it.² Dr. Sachs and his colleagues demonstrated that individualized and adequate nicotine replacement as a percentage of the nicotine metabolite cotinine present in the smoker's system substantially increased success rates.

Simply put, a three-pack-a-day smoker will probably need more nicotine replacement than a 15 cigarettes per day smoker. Dr. Sachs and others also have reported that high nicotine patch doses (up to three patches per day) were safe and well tolerated. Many smokers are surprised to hear this. We tell patients "clean and relatively slow nicotine is better than fast and dirty nicotine."

Bohadana and his colleagues performed the first double blind, placebo-controlled study to examine the efficacy and tolerability of a combination of the nicotine patch and nicotine inhaler.³ They found that the combination treatment significantly improved cessation rates to 12 months follow-up. Similarly, Blondal and colleagues have reported that a combination of nicotine nasal spray and nicotine patch significantly increased quit rates over nicotine patch alone.⁴ A meta-analysis of combination therapy studies reveals a 70 percent increase in quit rates at one-year follow-up over a single nicotine replacement therapy.

Deciding in which circumstances to use which medications and/or combinations of medications is as much art as science. Following are several helpful rules of thumb:

• Do not use the product package insert "one-size-fits-all" approach.

• Dosage and treatment durations need to be individualized.

• A more robust tobacco addiction more often requires a more aggressive treatment plan.

• Tobacco addiction medications demonstrate an orderly, dose-response treatment effect. Generally the higher the dose, the higher the cessation rate.

• Do not be fearful of using combination therapies.

• Patients with very intense situational tobacco cravings such as immediately after awakening may benefit from the rapid nicotine delivery of the nicotine nasal spray.

Other indicators of a greater degree of tobacco addiction and/or the need for a more aggressive treatment plan and/or need for combination therapies are:

• smoking more than 20 cigarettes per day

• smoking within five minutes of awakening or nocturnal smoking (waking up at night to smoke)

• a high carboxyhemogloblin level at intake

• smoking in forbidden places (We once worked with a smoker who was arrested after smoking in an airplane lavatory. It took an arrest for him to realize he had a tobacco addiction problem.)

• perceived "failure" with standard dosing nicotine replacement therapies (Remember: There are no failures–only smokers who have not yet succeeded.)

• a history of substance abuse in addition to tobacco.

HOW TO GET STARTED

Because spirometry and X-ray are the gold standards of pulmonary medicine, these are perfect opportunities to begin a dialogue with your smoking patients about quitting. Discuss the relationship of tobacco smoking to any observed airway obstruction, chest restriction, diffusion defects, hyperinflated lung fields, increased interstitial markings, and peribronchial cuffing and any other relevant findings.

Follow the As and the Rs with a prescription for a smoking cessation medication where appropriate. Give the patient a telephone call within three days to ensure that the patient is tolerating the medication. Remember to schedule a follow-up appointment within two weeks to assess progress and to titrate therapy and/or add medications.

Performing a simple carboxyhemoglobin assessment (CO breath monitor or blood test) and nicotine metabolite assay during each office visit can help the assessment of tobacco addiction and treatment planning. These medical procedures are inexpensive and are insurance reimbursable. Furthermore, many smokers are willing to pay out of pocket for a high quality successful smoking cessation program.

Your extra clinical efforts can produce tremendous results. You and your patients will be gratified and rewarded.

Reference List

May 2001 Issue:

Smoking Cessation Success
(5/01 Feature)

By Matthew P. Bars, MS, and Victor L. Marchione, MD, FCCP

Reference List:

1. Bars MP, Ferry LH, Proudfoot S. Eliminating barriers to tobacco control interventions in a medical office setting. Presentation at: The Society for Research on Nicotine and Tobacco Annual Meeting; June 13-14, 1997: Nashville, TN.
2. Sachs DPL, Benowitz, NL, Bostrom AG. Linearity of serum nicotine concentration and success of nicotine patch therapy in tobacco dependency treatment. In: Harris LS, ed. Problems of Drug Dependence, 1995: Proceedings of the 57th Annual Scientific Meeting, The College of Problems of Drug Dependence Inc, Volume II. Washington, DC: US Dept of Health and Human Services; 1996. NIDA Monograph 162.
3. Bohadana A, Nilsson F, Rasmussen T, Martinet Y. Nicotine inhaler and nicotine patch as a combination therapy for smoking cessation. Archives of Internal Medicine. 2000; 160.
4. Blondal T, Gudmundsson LJ, Clafsdottir L, Gutavsson G, Westin A. Nicotine Nasal Spray with nicotine patch for smoking cessation: randomized trial with six year follow up. BMJ. 1999;31: 285-288.

Bars has been engaged in the management and delivery of tobacco addiction services for more than 20 years. He is the program director of the Institute for Better Breathing IQuit Smoking Program, Jersey City, North Bergen and Secaucus, N.J., and is the director of the Smoking Consultation Service, which offers consultation services in establishing and managing medical smoking cessation services and pursuing reimbursement. He can be reached at mbars@StopSmokingDoctors.com or (800) 45-SMOKE. Dr. Marchione is a board certified pulmonologist and critical care specialist. He is engaged in a wide array of medical research studies and is currently the medical director of the IQuit Smoking Program and the Smoking Consultation Service. He can be reached at Vmarchione@StopSmokingDoctors.com.